1/29. nicotine dependence and withdrawal in an oncology setting: a risk factor for psychiatric comorbidity and treatment non-adherence.Highly nicotine dependent oncology patients are at high risk for psychiatric morbidity when they enter the medical care setting where smoking restrictions apply. nicotine withdrawal symptoms exacerbate cancer-related distress as well as common physical side effects of cancer treatment. This case report illustrates the management of a patient whose ongoing treatment for bladder cancer was jeopardized as a result of nicotine dependence and withdrawal. Several associated complications are described, the most serious of which were his acute anxiety and non-adherence to medical recommendations. A short-term management approach that included anxiolytics and nicotine replacement was effectively used to reduce this patient's excessive anxiety and thus facilitate compliance with stressful treatments. The severity of complications that can result from untreated nicotine dependence and withdrawal underscores the importance of assessing and monitoring smoking status in every patient. Greater staff awareness of the clinical practice guidelines regarding the diagnosis and treatment of nicotine dependence will likely result in improved patient care and compliance.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
2/29. Gamma-hydroxybutyrate withdrawal syndrome.STUDY OBJECTIVE: Gamma-hydroxybutyrate (GHB) withdrawal syndrome is increasingly encountered in emergency departments among patients presenting for health care after discontinuing frequent GHB use. This report describes the characteristics, course, and symptoms of this syndrome. methods: A retrospective review of poison center records identified 7 consecutive cases in which patients reporting excessive GHB use were admitted for symptoms consistent with a sedative withdrawal syndrome. One additional case identified by a medical examiner was brought to our attention. These medical records were reviewed extracting demographic information, reason for presentation and use, concurrent drug use, toxicology screenings, and the onset and duration of clinical signs and symptoms. RESULTS: Eight patients had a prolonged withdrawal course after discontinuing chronic use of GHB. All patients in this series were psychotic and severely agitated, requiring physical restraint and sedation. Cardiovascular effects included mild tachycardia and hypertension. Neurologic effects of prolonged delirium with auditory and visual hallucinations became episodic as the syndrome waned. Diaphoresis, nausea, and vomiting occurred less frequently. The onset of withdrawal symptoms in these patients was rapid (1 to 6 hours after the last dose) and symptoms were prolonged (5 to 15 days). One death occurred on hospital day 13 as withdrawal symptoms were resolving. CONCLUSION: In our patients, severe GHB dependence followed frequent ingestion every 1 to 3 hours around-the-clock. The withdrawal syndrome was accompanied initially by symptoms of anxiety, insomnia, and tremor that developed soon after GHB discontinuation. These initial symptoms may progress to severe delirium with autonomic instability.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
3/29. Narcotic withdrawal syndrome following gastric bypass--a difficult diagnosis.BACKGROUND: It is common for bariatric patients to experience postoperative nausea, depression and remorse for several months following surgery. Difficulty exists for the surgeon in delineating the physical from the psychological in treating these patients. Preoperative education, evaluation and preparation, although essential, will not identify nor eliminate all potential problems. methods: We report the case history of a patient who ultimately underwent reversal of her gastric bypass. Her symptoms required multiple procedures and hospital admissions for what appeared to be anatomical problems. All procedures were done laparoscopically. RESULTS: The patient's main complaints of persistent nausea and abdominal pain combined with radiographic evidence of sub-optimal anatomic construct led to multiple operative procedures. Psychological intervention relative to the persistent nausea and abdominal pain was ineffectual, although the supportive and consistent nature of the psychotherapy relationship was useful in overall patient stability and emotional well being. Complete reversal of the bypass did not effect improvement. Ultimately, the diagnosis of narcotic withdrawal prompted the institution of methadone treatment with complete cessation of the symptoms of nausea and pain. CONCLUSIONS: The diagnosis of narcotic withdrawal syndrome can be difficult in the postoperative bariatric patient. Psychological evaluation and support are essential elements of the program throughout the entire course of a patient's treatment experience. Laparoscopic techniques simplified the surgical care of this patient.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
4/29. Misuse and abuse of diazepam: an increasingly common medical problem.Misuse and abuse of diazepam among addiction-prone individuals is reported. The most common pattern of abuse appears to be periodic ingestion of 30 to 80 mg of diazepam in one dose, either alone or in conjunction with methadone or other narcotics. Two cases of physical dependency to diazepam have been observed. Many addict patients using diazepam are buying it on "the streets". All physicians should know that diazepam abuse and misuse is occurring, and careful attention should be given to prescribing, transporting and storing this drug.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
5/29. cyproheptadine for intrathecal baclofen withdrawal.OBJECTIVE: To evaluate the efficacy of cyproheptadine in the management of acute intrathecal baclofen (ITB) withdrawal. DESIGN: Descriptive case series. SETTING: University hospital with a comprehensive in- and outpatient rehabilitation center. PARTICIPANTS: Four patients (3 with spinal cord injury, 1 with cerebral palsy) with implanted ITB infusion pumps for treatment of severe spasticity, who had ITB withdrawal syndrome because of interruption of ITB infusion. INTERVENTIONS: patients were treated with 4 to 8mg of cyproheptadine by mouth every 6 to 8 hours, 5 to 10mg of diazepam by mouth every 6 to 12 hours, 10 to 20mg of baclofen by mouth every 6 hours, and ITB boluses in some cases. MAIN OUTCOME MEASURES: Clinical signs and symptoms of ITB withdrawal of varying severity were assessed by vital signs (temperature, heart rate), physical examination (reflexes, tone, clonus), and patient report of symptoms (itching, nausea, headache, malaise). RESULTS: The patients in our series improved significantly when the serotonin antagonist cyproheptadine was added to their regimens. fever dropped at least 1.5 degrees C, and heart rate dropped from rates of 120 to 140 to less than 100bpm. Reflexes, tone, and myoclonus also decreased. patients reported dramatic reduction in itching after cyproheptadine. These changes were associated temporally with cyproheptadine dosing. DISCUSSION: Acute ITB withdrawal syndrome occurs frequently in cases of malfunctioning intrathecal infusion pumps or catheters. The syndrome commonly presents with pruritus and increased muscle tone. It can progress rapidly to high fever, altered mental status, seizures, profound muscle rigidity, rhabdomyolysis, brain injury, and death. Current therapy with oral baclofen and benzodiazepines is useful but has variable success, particularly in severe cases. We note that ITB withdrawal is similar to serotonergic syndromes, such as in overdoses of selective serotonin reuptake inhibitors or the popular drug of abuse 3,4-methylenedioxymethamphetamine (Ecstasy). We postulate that ITB withdrawal may be a form of serotonergic syndrome that occurs from loss of gamma-aminobutyric acid B receptor-mediated presynaptic inhibition of serotonin. CONCLUSION: cyproheptadine may be a useful adjunct to baclofen and benzodiazepines in the management of acute ITB withdrawal syndrome.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
6/29. ether: a forgotten addiction.Among abused inhalants, ether has recently received little attention. The case of a patient suffering from ether dependence is reported. Whereas several features of DSM-IV dependence were fulfilled, no physical withdrawal signs were observed.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
7/29. The use of dexmedetomidine to facilitate opioid and benzodiazepine detoxification in an infant.Prolonged use of opioids and benzodiazepines for the care of critically ill infants and children can generate physical dependence. We present a case of an 8-mo-old infant with Hunter's syndrome who was maintained on very large doses of fentanyl and midazolam and who could not be weaned from these drugs by conventional taper. We used dexmedetomidine, an alpha(2)-adrenergic agonist, to facilitate opioid and benzodiazepine withdrawal. A processed electroencephalogram (Bispectral Index) was used to guide the titration of dexmedetomidine in this neurologically impaired infant. This is the first report of this drug being used in an infant to manage chemical dependence withdrawal. IMPLICATIONS: dexmedetomidine was used to facilitate opioid and benzodiazepine withdrawal in an 8-mo-old infant. A processed electroencephalogram (Bispectral Index) was used to guide the titration of dexmedetomidine in this neurologically impaired infant. This is the first report of dexmedetomidine use in an infant to manage chemical dependence withdrawal.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
8/29. dextromethorphan psychosis, dependence and physical withdrawal.As part of a synthesis of evidence regarding the abuse and addiction liability of dextromethorphan (DM), an over-the-counter cough medicine available in over 140 preparations, an uncommonly published case of dextromethorphan dependence (addiction) is described, with specific, rarely published complications. The individual was interviewed and several medical databases were also reviewed (medline, 1966-present; pubmed) for all content relating to the Keywords: dextromethorphan, abuse, dependence, cough medicine, addiction, withdrawal, psychosis. The patient evidenced history suggesting substance dependence, substance-induced psychosis and substance withdrawal in relation to DM. A literature review revealed that DM has specific serotonergic and sigma-1 opioidergic properties. dextrorphan (DOR), the active metabolite of DM, has similar properties; however, DOR is a weaker sigma opioid receptor agonist, and a stronger NMDA receptor antagonist. DM and DOR display specific biological features of addiction, and are capable of inducing specific psychiatric sequelae. A specific, reproducible toxidrome with significant psychiatric effects occurred, when DM was abused at greater than indicated doses, with more profound and potentially life-threatening effects at even higher doses. DM withdrawal appears evident. DM's active metabolite, DOR, has pharmacodynamic properties and intoxication effects similar to dissociatives, and may be more responsible for the dissociative effect that this DM abuser sought. However, it is this same metabolite that may be fraught with the potentially life-threatening psychoses and dissociative-induced accidents, as well as addiction. While DM has been hypothesized as the most commonly abused dissociative, health-care providers seem largely unaware of its toxidrome and addiction liability.- - - - - - - - - - ranking = 4keywords = physical (Clic here for more details about this article) |
9/29. bradycardia during methadone therapy in an infant.OBJECTIVES: To report the occurrence of bradycardia associated with the use of methadone administered to prevent withdrawal in an infant with physical tolerance following long-term opioid therapy in the pediatric intensive care unit setting. DESIGN: Retrospective case report. patients AND RESULTS: methadone (0.1 mg/kg) was administered to a 6-month-old infant following prolonged use of intravenous fentanyl for sedation during respiratory failure requiring mechanical ventilation. Approximately 30-60 mins after the first dosing of methadone, the infant's heart rate decreased from his baseline of 130-140 beats/min to 80-90 beats/min for 30 seconds. After the third dose of methadone, the heart rate decreased to a sinus bradycardia of 60-70 beats/min for 4 mins. The episodes resolved with tactile stimulation. Over the next 18 hrs, there were repeated episodes of bradycardia. None of these episodes were associated with hypotension, apnea, change in oxygen saturation, decreased peripheral perfusion, or other signs of hemodynamic instability. The methadone was withdrawn and the intravenous fentanyl infusion was restarted. Eight to 10 hrs after administration of the last dose of methadone, the episodes of bradycardia resolved and the patient remained in a normal sinus rhythm with a heart rate of 120-140 beats/min. CONCLUSION: methadone's three-dimensional structure shares similarities with calcium channel antagonists. Although it has been reported in the adult literature, there are no previous reports of bradycardia occurring with methadone therapy in infants. Although there were no deleterious physiologic effects related to the bradycardia in our patient, methadone should be used cautiously in patients who may not tolerate alterations in heart rate.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
10/29. Abrupt discontinuation of psychotropic drugs following confirmation of pregnancy: a risky practice.A number of pregnant women suffer from psychiatric disorders that require treatment with psychotropic drugs. A literature review suggests that these medications are relatively safe to use during pregnancy. Abrupt discontinuation of these drugs can have both physiological and psychological ramifications, which include unpleasant physical symptoms and re-emergence of the psychiatric condition. Therefore, it is not good practice to discontinue these medications abruptly upon diagnosis of pregnancy.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
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